AMA Journal of Ethics

Formerly Virtual Mentor

Illuminating the art of medicine

Accountability in Rationing

Introduction to the November 2012 issue of Virtual Mentor on the topic of improving allocation of limited resources.

Ethical dilemmas in modern medical practice often arise from the tension between the noble position that physicians hold, in their own eyes and the eyes of society, and the realities of resource limitations, including physician time, available medical services, and especially money. However much we would like to extend to every patient the best and most comprehensive therapies known, the reality is that resource rationing is already in place in our health care system and is set to take an increasingly prominent and recognized role in medical practice as America attempts to control its debt. This issue of Virtual Mentor attempts to identify areas of medicine in which additional rationing of resources may be ethically tenable…and those in which it is not.

How is it that America’s health care policies have come to be what they are? In this month’s medicine and society section, Michael K. Gusmano, PhD, elucidates some of the ways in which national resources come to be disproportionately allocated to specific medical causes and patient populations. In the history of medicine section, Will Ross, MD, MPH, recounts the story of Medicare’s End Stage Renal Disease program, one of the longest-running and most costly of our government’s health care expenditures, and questions whether it is still a sensible program to fund—or indeed, whether it ever was. In the health law section, Valarie Blake, JD, MA, updates us on the Supreme Court’s mixed ruling on the constitutionality of the Patient Protection and Affordable Care Act (ACA).

Our health care system’s resource limitations pose dilemmas for individual physicians and other health care providers every day. Narayan Iyer, MD, and Sabine Iben, MD, confront the volatile situation that arises when practical and economic considerations clash with a family’s wishes, and a life hangs in the balance. They untangle the snarl of idealism, practicality, hope, and justice that surround this sensitive decision. Katherine J. Mathews, MD, MPH, MBA, explores the consequences of patients’ self-rationing that results from their economic constraints and advises physicians about how to help such patients access necessary treatment instead of forgoing care. Finally, Ronald MacKenzie, MD, Matthew Matava, MD, and Charles Carroll, IV, MD, consider the case of a patient who requests a costly procedure that may help him, but which evidence suggests may merely be an expensive placebo.

Two articles look at technical innovations that may have implications for efforts to balance our medical budget. In our state of the art and science section, Siddharth Devarakonda, MD, Ramaswamy Govindan, MD, and Peter S. Hammerman, MD, PhD, explain what next-generation gene sequencing could do for cancer therapies, concluding that, as the cost of gene sequencing declines, effective targeted therapies personalized to each patient’s tumor will be much more cost-efficient to develop than the standard selection of often-noxious chemotherapy agents. In their journal discussion article, David S. Gierada, MD, and Lawrence M. Kotner Jr., MD, consider the ethics of low-dose CT screening for lung cancer, including whether the costs and risks of the screening are appropriate for various patient populations.

This issue also includes some suggestions for how medical resources might be more efficiently allocated in the future. In the medical education section, Betsy Goebel Jones, EdD, and Steven L. Berk, MD, provide a detailed account of Texas Tech’s Family Medicine Accelerated Track program, a recently accredited 3-year medical school program that produces well-trained doctors in less time and with less debt. In our first policy piece, Kevin Frick, PhD, assesses the new National Quality Forum guidelines designed to improve cost-efficiency in health care. The second policy forum piece, by Todd Ferguson, PhD, reviews the ABIM Foundation’s Choosing Wisely campaign, in which physicians and patients work together to develop treatment plans that are effective for the patient but are also efficient and promote the sustainable use of limited resources.

Finally, this issue considers the overall structure of our health care system. This month’s excerpts from the Code of Medical Ethics survey the ethical landscape of various cost-containment schemes, including managed care, capitation, and physician pay-for-performance. In an op-ed, Ed Weisbart, MD, CPE, argues that some aspects of our health care system are fundamentally unsustainable even with the ACA’s changes, and proposes that a single-payer system would do much to alleviate our budgetary crisis and improve care.